What’s app: +66 819892565​

What’s app: +66 819892565​

Medical Inquiry Form​

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Contact Information​

First Name​ :

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E-mail Address :​

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Address :​

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Emergency Contact Information​

Last Name :​

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First Name​ :

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E-mail Address :​

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Phone :​

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Address :​

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Address2 :​

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City :​

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State :​

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Zip/Postal Code :​

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Country :​

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Requested Procedure​

(Please provide us with as much detail as possible).​

Please tell us which procedure you are interested in receiving:​

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Why are you interested in receiving the above procedure?​

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(Please be as honest as possible when responding to the above question - it is important that the doctor truly understands the purpose).    

General Information/Statistics​

Gender​ :

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( Please specific )​

Height :​

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Centimeter​

Weight :​

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Kilogram​

Date

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Date of Birth ​​

Month​

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Year​

This field is required.

Medical Conditions​

Are you/have you ever had:​

Aids or HIV positive :​

Yes
No

This field is required.

Anemia :​

Yes
No

This field is required.

Arthritis :​

Yes
No

This field is required.

Asthma :​

Yes
No

This field is required.

Back Problems :​

Yes
No

This field is required.

Blood Clots :​

Yes
No

This field is required.

Blood Disorders :​

Yes
No

This field is required.

Blood Disorders :​

Yes
No

This field is required.

Cancer :​

Yes
No

This field is required.

Bleeding Problems ​:​

Yes
No

This field is required.

Chest Pains :​

Yes
No

This field is required.

Colitis :​

Yes
No

This field is required.

Depression :​

Yes
No

This field is required.

Diabetes :​

Yes
No

This field is required.

Ear Problems :​

Yes
No

This field is required.

Eye Problems :​

Yes
No

This field is required.

Epilepsy :​

Yes
No

This field is required.

Heart Problems  :​

Yes
No

This field is required.

Eye Problems :​

Yes
No

This field is required.

Hepatitis :​

Yes
No

This field is required.

High Blood Pressure :​

Yes
No

This field is required.

Heart Problems  :​

Yes
No

This field is required.

Irregular Heartbeat :​

Yes
No

This field is required.

Stroke :​

Yes
No

This field is required.

Any psychiatric conditions :​

Yes
No

This field is required.

Migraine Headaches :​

Yes
No

This field is required.

Seizures  :​

Yes
No

This field is required.

Nose/Throat Problems :​

Yes
No

This field is required.

Pneumonia :​

Yes
No

This field is required.

Shortness of Breath :​

Yes
No

This field is required.

Rheumatic Fever :​

Yes
No

This field is required.

Stomach Problems :​

Yes
No

This field is required.

Transfusion :​

Yes
No

This field is required.

Thyroid Problems :​

Yes
No

This field is required.

For Women Only​

Do you take birth control pills or any hormone replacement medication or patches? :​

Yes
No

This field is required.

Are you pregnant ?​ :

Yes
No

This field is required.

(Pregnant women must take a pregnancy test before departure as most pregnancies can disrupt surgery)​

Medical History​

In the past 18 months, have you been hospitalized, had surgery or received medical treatment, pregnancy delivery, or ambulatory surgery :​

Yes
No

This field is required.

What was your date of surgery? :​

This field is required.

What was your reason for surgery? :​

This field is required.

Which procedure did you have? :​

This field is required.

What was your net weight change since surgery? :​

This field is required.

Do you have difficulty with healing or scarring? :​

Yes
No

This field is required.

Have you had cosmetic surgery in the past ? :​

Yes
No

This field is required.

If yes, please explain how your experience was : ​

This field is required.

Please list any other past surgeries :​

This field is required.

Medication​

Kindly list all the medication you take, along with the dosage: :​

This field is required.

Are you allergic to any medication? :​

Yes
No

This field is required.

If yes, please explain which medication(s) along with the reaction(s)​

This field is required.

Have you had problems with anesthesia? :​

Yes
No

This field is required.

Are you allergic to any type of food or latex? :​

Yes
No

This field is required.

Do you take any vitamins or herbal supplements? :​

Yes
No

This field is required.

If yes, please explain which ones :​

This field is required.

Do you smoke ?​

Yes
No

This field is required.

If yes, please explain which ones :​

This field is required.

Do you drink alcohol ?​

Yes
No

This field is required.

If yes, how much? Per day, per week, per month ?​

This field is required.

Send

Last Name :​

This field is required.

Thank You!

The form has been successfully sent.

Contact Information​

First Name​ :

This field is required.

E-mail Address :​

This field is required.

Phone :​

This field is required.

Address :​

This field is required.

Address2 :​

This field is required.

City :​

This field is required.

State :​

This field is required.

Zip/Postal Code :​

This field is required.

Country :​

This field is required.

Emergency Contact Information​

Last Name :​

This field is required.

First Name​ :

This field is required.

E-mail Address :​

This field is required.

Phone :​

This field is required.

Address :​

This field is required.

Address2 :​

This field is required.

City :​

This field is required.

State :​

This field is required.

Zip/Postal Code :​

This field is required.

Country :​

This field is required.

Requested Procedure​

(Please provide us with as much detail as possible).​

Please tell us which procedure you are interested in receiving:​

This field is required.

Why are you interested in receiving the above procedure?​

This field is required.

(Please be as honest as possible when responding to the above question - it is important that the doctor truly understands the purpose).    

General Information/Statistics​

Gender​ :

This field is required.

( Please specific )​

Height :​

This field is required.

Centimeter​

Weight :​

This field is required.

Kilogram​

Date

This field is required.

Date of Birth ​​

Month​

This field is required.

Year​

This field is required.

Medical Conditions​

Are you/have you ever had:​

Aids or HIV positive :​

Yes
No

This field is required.

Anemia :​

Yes
No

This field is required.

Arthritis :​

Yes
No

This field is required.

Asthma :​

Yes
No

This field is required.

Back Problems :​

Yes
No

This field is required.

Blood Clots :​

Yes
No

This field is required.

Blood Disorders :​

Yes
No

This field is required.

Blood Disorders :​

Yes
No

This field is required.

Cancer :​

Yes
No

This field is required.

Bleeding Problems ​:​

Yes
No

This field is required.

Chest Pains :​

Yes
No

This field is required.

Colitis :​

Yes
No

This field is required.

Depression :​

Yes
No

This field is required.

Diabetes :​

Yes
No

This field is required.

Ear Problems :​

Yes
No

This field is required.

Eye Problems :​

Yes
No

This field is required.

Epilepsy :​

Yes
No

This field is required.

Heart Problems  :​

Yes
No

This field is required.

Eye Problems :​

Yes
No

This field is required.

Hepatitis :​

Yes
No

This field is required.

High Blood Pressure :​

Yes
No

This field is required.

Heart Problems  :​

Yes
No

This field is required.

Irregular Heartbeat :​

Yes
No

This field is required.

Stroke :​

Yes
No

This field is required.

Any psychiatric conditions :​

Yes
No

This field is required.

Migraine Headaches :​

Yes
No

This field is required.

Seizures  :​

Yes
No

This field is required.

Nose/Throat Problems :​

Yes
No

This field is required.

Pneumonia :​

Yes
No

This field is required.

Shortness of Breath :​

Yes
No

This field is required.

Rheumatic Fever :​

Yes
No

This field is required.

Stomach Problems :​

Yes
No

This field is required.

Transfusion :​

Yes
No

This field is required.

Thyroid Problems :​

Yes
No

This field is required.

For Women Only​

Do you take birth control pills or any hormone replacement medication or patches? :​

Yes
No

This field is required.

Are you pregnant ?​ :

Yes
No

This field is required.

(Pregnant women must take a pregnancy test before departure as most pregnancies can disrupt surgery)​

Medical History​

In the past 18 months, have you been hospitalized, had surgery or received medical treatment, pregnancy delivery, or ambulatory surgery :​

Yes
No

This field is required.

What was your date of surgery? :​

This field is required.

What was your reason for surgery? :​

This field is required.

Which procedure did you have? :​

This field is required.

What was your net weight change since surgery? :​

This field is required.

Do you have difficulty with healing or scarring? :​

Yes
No

This field is required.

Have you had cosmetic surgery in the past ? :​

Yes
No

This field is required.

If yes, please explain how your experience was : ​

This field is required.

Please list any other past surgeries :​

This field is required.

Medication​

Kindly list all the medication you take, along with the dosage: :​

This field is required.

Are you allergic to any medication? :​

Yes
No

This field is required.

If yes, please explain which medication(s) along with the reaction(s)​

This field is required.

Have you had problems with anesthesia? :​

Yes
No

This field is required.

Are you allergic to any type of food or latex? :​

Yes
No

This field is required.

Do you take any vitamins or herbal supplements? :​

Yes
No

This field is required.

If yes, please explain which ones :​

This field is required.

Do you smoke ?​

Yes
No

This field is required.

If yes, please explain which ones :​

This field is required.

Do you drink alcohol ?​

Yes
No

This field is required.

If yes, how much? Per day, per week, per month ?​

This field is required.

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